Overtreatment, or the use of treatment where the burden significantly outweighs the benefits, is an important patient safety issue for end-stage renal disease (ESRD) patients. According to clinical practice guidelines, not all patients with ESRD are appropriate for initiation or continuation of dialysis. The demands of the treatment may outweigh the benefits for these patients because dialysis may not adequately maintain or restore function and may cause or increase suffering. In these situations, patients, their families, and their health care providers need to discuss either withholding or withdrawing dialysis treatment, and initiating palliative care; however, the literature suggests that these conversations are either not occurring or are occurring too late, often when patients are unable to speak for themselves. The majority of the palliative care research in ESRD has examined patients' expectations or preferences. There is a paucity of articles including nephrologists or nephrology fellows. Further, the majority of the latter research includes little or no examination of the interaction between patients and nephrologists regarding palliative care discussions. Some have conjectured about the barriers nephrologists may face, but no one has comprehensively explored this issue with nephrologists and nephrology fellows. Further, barriers to palliative care discussions identified among other disease specialists - e.g., oncologists - may not be the same as those faced by nephrologists, particularly since ESRD has no cure and requires continued treatment to sustain life. This multiphase mixed methods study of nephrologists and nephrology fellows is designed to address the research gaps. The purpose is to: 1) Explore the barriers and facilitators to discussions with patients and their families regarding palliative care as identified by nephrologists and nephrology fellows; 2) Rank order the barriers and facilitators to discussions with patients and their families regarding palliative care; and 3) Determine if there are differences in barriers by experience level (i.e., nephrology fellows versus practicing nephrologists). The first study phase consists of semi-structured interviews with nephrologists and nephrology fellows. The second phase uses a nominal group process in which nephrologists and nephrology fellows are asked to identify and rank barriers and facilitators to renal palliative care discussions. Because it is likely that multiple barriers nd facilitators will be identified, ranking of the top factors will allow for comparison between group, based on experience. Long term, this prioritization may be useful in developing skill-based training and curricula tailored to the needs of nephrologists and nephrology fellows.